Improving primary care residents’ proficiency in the diagnosis of skin cancer

Abstract

OBJECTIVE:To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists. PARTICIPANTS:Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest. DESIGN:A randomized, controlled trial with pretest and posttest measurements of residents' ability to diagnose and make evaluation plans for lesions indicative of skin cancer. INTERVENTION:The intervention included face-to-face feedback sessions focusing on residents' performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide. MEASUREMENTS AND MAIN RESULTS:We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer-malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p Ͻ .05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p Ͻ .05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p Ͻ .01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma. I n the United States, managed care organizations currently rely on primary care physicians to triage for many specialized areas of medicine, including dermatology. Successful triaging involves screening, making correct initial diagnosis and evaluation planning decisions, and appropriately referring to specialists. Because many of these managed care organizations use financial incentives and administrative mechanisms to encourage generalists to limit referrals to specialists, 1 we must ensure that primary care physicians can screen, diagnose, and evaluate effectively with reduced access to specialists. In dermatology, primary care physicians may not need to be as skilled as dermatologists at diagnosing and planning treatment for the approximately 2,000 named skin diseases, 2 but, at a minimum, they need to proficiently screen, diagnose, and evaluate lesions indicative of skin cancer. 3 In this study, we focused on improving primary care residents' performance on diagnosing and making evaluation plans for lesions indicative of skin cancer. CONCLUSIONS:Primary care physicians have the opportunity to play a major role in the early detection of skin cancer. Up...

Skin Cancer Examination Teaching in US Medical Education

“…11 This underscores the need for practical hands-on training and practice opportunities. Previous studies have described targeted educational interventions that have improved clinicians' ability to diagnose and plan evaluation strategies for cancerous skin lesions 12,13 and that have increased medical students' self-rated skill levels for cancer prevention and detection. 10 Teaching of the SCE seems to be suboptimal in the 7 medical schools studied, based on students' self-rated low skill levels.…”

Effects on Skills and Practice from a Web-Based Skin Cancer Course for Primary Care Providers

“…The dermatology workforce is limited, and studies have found that PCPs can diagnose and appropriately refer melanoma at the same level as dermatologists if they receive targeted education. 8,9 Skin cancer training programs, both in person and web-based, have been shown to improve the knowledge and skills of PCPs, which is important because as few as 30% of primary care residents report receiving formal training in performing a skin examination. 6,8,10 -12 Few educational programs for skin cancer detection have been developed, and even fewer for practicing PCPs in particular.…”

Decision Support Software to Help Primary Care Physicians Triage Skin Cancer

“…Physicians' overall triage error rate using the decision support software (13.3%) was similar to the triage error rate found for dermatologists in a recent study (15%). 5 Nineteen of 20 physicians made more correct triage decisions using the software than on their own, and physicians using the software averaged 3 more correct triage decisions than when they triaged on their own, representing a 20% improvement rate. Regarding cancerous lesions, primary care physicians' error rate using the decision support software (3.6%) was similar to that achieved by dermatologists in a previous study (0%).…”

“…Regarding cancerous lesions, primary care physicians' error rate using the decision support software (3.6%) was similar to that achieved by dermatologists in a previous study (0%). 5 In addition, unnecessary referrals and biopsies were reduced by half when physicians used the decision support software. These findings are especially encouraging given that 18 participants (90%) rated themselves between "somewhat" and "not at all" confident in their skin cancer triage skills.…”

“…Ample data [1][2][3][4] suggest that primary care physicians are inadequate at diagnosing skin lesions, including cancerous ones. Interventions to improve primary care physicians' skills in this area have produced mixed results; one multicomponent intervention 5 significantly improved primary care physicians' ability to correctly diagnose and provide evaluation plans for skin lesions, whereas several other interventions 6,7 have failed to improve their skills. Even with exposure to an effective educational intervention, primary care physicians are likely to need ongoing support over time to maintain or enhance their learning.…”